Provider Demographics
NPI:1588623318
Name:KISHWAUKEE COMMUNITY HEALTH SERVICES CENTER
Entity Type:Organization
Organization Name:KISHWAUKEE COMMUNITY HEALTH SERVICES CENTER
Other - Org Name:HAUSER-ROSS SURGICENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:SYKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-756-8574
Mailing Address - Street 1:2240 GATEWAY DR
Mailing Address - Street 2:
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178
Mailing Address - Country:US
Mailing Address - Phone:815-756-8571
Mailing Address - Fax:815-756-1226
Practice Address - Street 1:2240 GATEWAY DR
Practice Address - Street 2:
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178
Practice Address - Country:US
Practice Address - Phone:815-756-8571
Practice Address - Fax:815-756-1226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-21
Last Update Date:2009-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========003Medicaid
IL554780Medicare PIN